During an assessment under our new approach
Date of assessment: 23 February to 30 March 2026.
The service provides personal care support to adults and people with a learning disability in their own home. At the time of the assessment the service was supporting 34 people with a regulated activity. This assessment was carried out in response to the rating of requires improvement at the last assessment and due to safeguarding concerns, we received about the service.
At the time of the assessment there were no people using the service who had a learning disability. As a result, we were not able to assess the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
The service had still not fully implemented an effective system to manage the governance of the service, and we still identified some shortfalls. For example, we still saw some care plans and risk assessment had incomplete, inconsistence or missing information. This meant staff did not always have clear and accurate guidance to deliver safe and consistent care. Assessments of individuals’ needs were still not always reflected clearly or comprehensively in care plans. This meant care planning did not always provide a reliable picture of the support people required. Some documentation in relation to medicines was also still not completed comprehensively. This meant there was a risk that medicines may not always be managed safely.
Safe recruitment practices had improved but were still not always being completed in line with the provider’s policy and legislation. This meant staff employed may not be suitable to work with vulnerable people.
Mental Capacity Assessments (MCAs), required under the Mental Capacity Act 2005, were not being completed for people who may lack capacity. This meant decisions about their care may not have been made lawfully or in their best interests.
We found no evidence that people had come to harm because of these shortfalls.
However, new quality systems had been added since the last inspection to strengthen the oversight of risk and performance.We now saw recent audits had identified the need to further review assessments, care plans and risk assessments to ensure they were effective. A service improvement plan was in place, and the registered manager was progressing through the required actions. The provider was now notifying statutory agencies in line with their regulatory responsibilities.
Staff told us they felt supported by the service’s leadership and demonstrated an understanding of their roles and responsibilities when supporting people with a range of needs. Staff had also received appropriate training for their roles. There was a shared vision and culture within the service, and leaders demonstrated openness, honesty and transparency.
The service had made some improvements and were no longer in breach of safe care and treatment, failure to send notifications and staff being recruited safely.
We identified one breach of the legal requirement in relation to governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.